This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsil.com or by calling 1-800-458-6024. Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $750 Individual/ Family is equivalent to 3 individual deductibles Doesn t apply to certain preventative care. Yes. $300 deductible for out-ofnetwork hospital admission. There are no other specific deductibles. Yes. For In-Network $1,750 Individual /Family is equivalent to 3 individual out-ofpocket expense limits For Out-of-Network $3,250 Individual/Family is equivalent to 3 individual out-ofpocket expense limits Copay, prescription copay, premiums, prescription copay, balanced-billed charges and health care this plan doesn t cover. No. Yes. For a list of preferred providers, visit www.bcbsil.com or call 1-800-458-6024. No. Yes. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out of pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 1 of 8
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use In-Network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need In-Network Out-of-Network Limitations & Exceptions Primary care visit to treat an injury or illness $20 copay/visit 30% coinsurance Copay applies to office visit only. Specialist visit $30 copay/visit 30% coinsurance Copay applies to office visit only. Other practitioner office visit 10% coinsurance 30% coinsurance Chiropractic services are limited to a $1,000 calendar year maximum. Preventive care/screening/immunization No Charge 30% coinsurance ---none--- Diagnostic test (x-ray, blood work) 10% coinsurance 30% coinsurance ---none--- Imaging (CT/PET scans, MRIs) 10% coinsurance 30% coinsurance ---none--- 2 of 8
Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsil.com. If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Generic drugs Formulary brand drugs Non-formulary brand drugs In-Network $15 copay/ a 34 day supply $30 copay/ a 90 day supply 35% coinsurance/ a 34 day supply 35% coinsurance / a 90 day supply 50% coinsurance/ a 34 day supply 50% coinsurance/ a 90 day supply Out-of-Network $15 copay/ prescription for up to a 34 day supply 35% coinsurance/ prescription for up to a 34 day supply 50% coinsurance/ prescription for up to a 34 day supply Limitations & Exceptions Certain women s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. For Out-of-Network drug provider you are responsible for 25% of the eligible amount after the copay. 34 day retail/90 day mail Certain women s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. Retail 34 day supply $15 minimum/ $150 maximum Mail 90 day supply $30 minimum/ $300 maximum 34 day retail/90 day mail Specialty drugs Covered Covered Coverage based on group policy. Facility fee (e.g., ambulatory surgery center) 10% coinsurance 30% coinsurance Physician/surgeon fees 10% coinsurance 30% coinsurance ---none--- Emergency room services 10% coinsurance 10% coinsurance ---none--- Emergency medical transportation 20% coinsurance 20% coinsurance ---none--- Urgent care 10% coinsurance 30% coinsurance ---none--- Facility fee (e.g., hospital room) 10% coinsurance 30% coinsurance Physician/surgeon fee 10% coinsurance 30% coinsurance ---none--- 3 of 8
Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need In-Network Out-of-Network Limitations & Exceptions Mental/Behavioral health outpatient services 10% coinsurance 30% coinsurance ---none--- Mental/Behavioral health inpatient services 10% coinsurance 30% coinsurance Substance use disorder outpatient services 10% coinsurance 30% coinsurance ---none--- Substance use disorder inpatient services 10% coinsurance 30% coinsurance Prenatal and postnatal care $20 copay 30% coinsurance Copay applies for the 1 st prenatal visit only. Delivery and all inpatient services 10% coinsurance 30% coinsurance Home health care 10% coinsurance 30% coinsurance ---none--- Rehabilitation services 10% coinsurance 30% coinsurance 100 visits per calendar year for Physical Therapy. 100 visits per calendar year for Habilitation services 10% coinsurance 30% coinsurance Occupational Therapy. 100 visits per calendar year for Speech Therapy. Skilled nursing care 10% coinsurance 30% coinsurance Benefits are limited to items used to serve Durable medical equipment 10% coinsurance 30% coinsurance a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). Hospice service 10% coinsurance 30% coinsurance Eye exam Not Covered Not Covered ---none--- Glasses Not Covered Not Covered ---none--- Dental check-up Not Covered Not Covered ---none--- 4 of 8
Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult) Hearing aids Long-term care Routine eye care (Adult) Routine foot care (with the exception of those with diabetes) Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic care Your Rights to Continue Coverage: Infertility treatment Most coverage provided outside the United States. See www.bcbsil.com. Non-emergency care when traveling outside the U.S Private-duty nursing (excluding inpatient services) If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-800-458-6024. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Blue Cross and Blue Shield of Illinois at 1-800-458-6024 or visit www.bcbsil.com, or contact the U.S Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) 527-9431 or visit http://insurance.illinois.gov. 5 of 8
Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-458-6024. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-458-6024. Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 1-800-458-6024. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-458-6024. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8
Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $6,090 Patient pays $1,450 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $750 Copays $40 Coinsurance $510 Limits or exclusions $150 Total $1,450 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,720 Patient pays $1,680 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $750 Copays $740 Coinsurance $110 Limits or exclusions $80 Total $1,680 7 of 8
Coverage Examples Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8